Neonatal mortality during the war in Tigray: a cross-sectional community-based study.

BACKGROUND: Neonatal mortality is among the key national and international indicators of health services. The global Sustainable Development Goal target for neonatal mortality is fewer than 12 deaths per 1000 livebirths, by 2030. Neonatal mortality estimates in the 2019 Ethiopian Demographic Health Survey found 25·7 deaths per 1000 livebirths. Subnational surveys specific to Tigray, Ethiopia, reported a neonatal mortality lifetime prevalence of 7·13 deaths. Another government report from the Tigray region estimated a neonatal mortality rate of ten deaths per 1000 livebirths in 2020. Despite the numerous interventions in Ethiopia's Tigray region to achieve the Sustainable Development Goals, the war has disrupted most health services, but the effect on neonatal mortality is unknown. Thus, this study aimed to investigate the magnitude and causes of neonatal mortality during the war in Tigray. METHODS: A cross-sectional community-based study was conducted in Tigray to evaluate neonatal mortality that occurred from Nov 4, 2020, to May 30, 2022. Among the 31 districts, 121 tabias were selected using computer-generated random sampling, and 189 087 households were visited. We adopted a validated WHO 2022 verbal autopsy tool, and data were collected using an interviewer-administrated Open Data Kit. In the absence of the mother, other respondents to the verbal autopsy interview were household members aged 18 years and older who provided care during the final illness that led to death. FINDINGS: 29 761 livebirths were recorded during the screening of 189 087 households. Verbal autopsy was administered for 1158 households with neonatal deaths. 317 neonates were stillborn, and 841 neonatal deaths were recorded with the WHO 2022 verbal autopsy tool from Nov 4, 2020, to May 30, 2022, in 31 districts. The neonatal mortality rate was 28·2 deaths per 1000 livebirths. 476 (57%) of the 841 neonatal deaths occurred at home and 296 (35%) in health facilities. A high rate of neonatal deaths was reported in rural districts (80% [673 of 841]) compared with urban districts (20% [168 of 841]), and 663 (79%) deaths occurred during the early neonatal period, in the first week of life (0-6 days). The leading causes of neonatal death were asphyxia (35% [291 of 834]), prematurity (30% [247 of 834]), and infection (12% [104 of 834]). Asphyxia (37% [246 of 663]) and infection (28% [50 of 178]) were the leading causes of death for early and late neonatal period deaths, respectively. INTERPRETATION: Neonatal mortality in Tigray is high due to preventable causes. An urgent response is needed to prevent the high number of neonatal deaths associated with the depleted health resources and services resulting from the war, and to achieve the Sustainable Development Goal on neonatal mortality. FUNDING: UNICEF and United Nations Fund for Population Activities. TRANSLATION: For the Tigrigna translation of the abstract see Supplementary Materials section.

Causes of death among women of reproductive age during the war in Tigray, Ethiopia.

BACKGROUND: In resource-limited countries with weak healthcare systems, women of reproductive age are particularly vulnerable during times of conflict. In Tigray, Ethiopia, where a war broke out on 04 November 2020, there is a lack of information on causes of death (CoD) among women of reproductive age. This study aims to determine the underlying CoD among women of reproductive age during the armed conflict in Tigray. METHODS: This community-based survey was carried out in six Tigray zones, excluding the western zone for security reasons. We used a multistage stratified cluster sampling method to select the smallest administrative unit known as Tabiya. Data were collected using a standardized 2022 WHO Verbal Autopsy (VA) tool. The collected data were analyzed using the InterVA model using R analytic software. The study reported both group-based and cause-specific mortality fractions. RESULTS: A total of 189,087 households were screened and 832 deaths were identified among women of reproductive age. The Global Burden of Disease classification showed that infectious and maternal disorders were the leading CoD, accounting for 42.9% of all deaths. External causes contributed to 26.4% of fatalities, where assault accounted for 13.2% of the deaths. Maternal deaths made up 30.0% of the overall mortality rate. HIV/AIDS was the primary CoD, responsible for 13.2% of all deaths and 54.0% of infectious causes. Other significant causes included obstetric hemorrhage (11.7%) and other and unspecified cardiac disease (6.6%). CONCLUSIONS: The high proportion of infectious diseases related CoD, including HIV/AIDS, as well as the occurrence of uncommon external CoD among women, such as assault, and a high proportion of maternal deaths are likely the result of the impact of war in the region. This highlights the urgent need for targeted interventions to address these issues and prioritize sexual and reproductive health as well as maternal health in Tigray.

Maternal sepsis and factors associated with poor maternal outcomes in a tertiary hospital in Tigray, Ethiopia: a retrospective chart review.

BACKGROUND: Maternal sepsis is the third leading cause of maternal death in the world. Women in resource-limited countries shoulder most of the burdens related to sepsis. Despite the growing risk associated with maternal sepsis, there are limited studies that have tried to assess the impact of maternal sepsis in resource-limited countries. The current study determined the outcomes of maternal sepsis and factors associated with having poor maternal outcomes. METHODS: A facility-based retrospective cross-sectional study design was employed to assess the clinical presentation, maternal outcomes, and factors associated with maternal sepsis. The study was conducted in Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia, from January 1, 2017, to December 31, 2021. Sociodemographic characteristics, clinical characteristics and outcomes of women with maternal sepsis were analyzed using a descriptive statistic. The association between dependent and independent variables was determined using multivariate logistic regression. RESULTS: Among 27,350 live births, 298 mothers developed sepsis, giving a rate of 109 maternal sepsis for every 10,000 live births. There were 22 maternal deaths, giving rise to a case fatality rate of 7.4% and a maternal mortality ratio of 75 per 100,000 live births. Admission to the intensive care unit and use of mechanical ventilator were observed in 23.5% and 14.1% of the study participants, respectively. A fourth (24.2%) of the mothers were complicated with septic shock. Overall, 24.2% of women with maternal sepsis had severe maternal outcomes (SMO). Prolonged hospital stay, having parity of two and above, having the lung as the focus of infection, switchof antibiotics, and developing septic shock were significantly associated with SMO. CONCLUSIONS: This study revealed that maternal sepsis continues to cause significant morbidity and mortality in resource-limited settings; with a significant number of women experiencing death, intensive care unit admission, and intubation attributable to sepsis. The unavailability of recommended diagnostic modalities and management options has led to the grave outcomes observed in this study. To ward off the effects of infection during pregnancy, labor and postpartum period and to prevent progression to sepsis and septic shock in low-income countries, we recommend that concerted and meticulous efforts should be applied to build the diagnostic capacity of health facilities, to have effective infection prevention and control practice, and to avail recommended diagnostic and management options.

Maternal mortality during war time in Tigray, Ethiopia: A community-based study.

OBJECTIVE: This study seeks to examine the impact of war on maternal mortality following an exacerbation in the dynamics of inequality in maternal health caused by the continuing conflict. DESIGN: Community-based cross-sectional study. SETTING: Tigray region of Northern Ethiopia, between November 2020 and May 2022. POPULATION: This study surveyed a total of 189 087 households from six of the seven zones of Tigray in 121 tabiyas from 31 districts selected. A multistage cluster sampling technique was used to select the districts and tabiyas. METHODS: The study was conducted in two phases. In the first phase, reproductive-age deaths that occurred during the study period were screened. In the second phase, verbal autopsies were conducted at the screened households. MAIN OUTCOME MEASURES: Maternal mortality ratio level and cause-specific mortality. RESULTS: The results of the study showed that the maternal mortality ratio was 840 (95% CI 739-914) per 100 000 live births. Haemorrhage, 107 (42.8%), pregnancy-induced hypertension, 21 (8.4%), and accidents, 14 (5.6%), were the main causes of mortality. Additionally, 203 (81.2%) of the mothers died outside of a health facility. CONCLUSIONS: This study has shown a higher maternal mortality ratio following the dynamics of the Tigray war, as compared with the pre-war level of 186/100 000. Furthermore, potentially many of the pregnancy-related deaths could have been prevented with access to preventive and emergency services. Given the destruction and looting of many facilities, the restoration and improvement of the Tigray health system must take precedence.

Impact of a double catastrophe, war and COVID-19, on health service utilization of a tertiary care hospital in Tigray: an interrupted time-series study.

BACKGROUND: In developing nations with fragile healthcare systems, the effect of war is likely to be much worse than it would be in more developed countries. The presence of COVID-19 will also likely exacerbate the war's impact. This study set out to determine the effect of armed conflict and the COVID-19 pandemic on health service utilization at Ayder Comprehensive Specialized Hospital, in the Tigray region of Ethiopia. METHODS: An interrupted time-series study design was used to analyze patient visits over forty-eight consecutive months (from July 2017 to June 2021) at inpatient, outpatient, and emergency departments. Data were analyzed using segmented regression analysis with a defined outcome of level and trend changes in the number of patient visits. In addition, negative binomial regression analysis was also used to estimate the impact of both COVID-19 and the war on patient flow. RESULTS: There were 59,935 admissions, 876,533 outpatient visits, and 127,872 emergency room visits. The effect of COVID-19 was seen as soon as the Tigray regional government imposed comprehensive restrictions. Immediately after COVID-19 appeared, all the service areas exhibited a significant monthly drop in visits; [-35.6% (95% CI: -48.2%, -23.1%)] for inpatient, [-60.6% (95% CI: -71.6%, -49.5%)] for outpatient, and [-44.1% (95% CI: -59.5%, -28.7%)] for emergency department visits. The impact of the war became apparent after a lag time of one month. Controlling the effects of time and COVID-19, the war led to a significant fall in inpatient visits [-44.3% (95% CI: -67.2%, -21.5%)], outpatients [-52.1% (95% CI: -82.7%, -21.5%)], and emergency-room attendances [-45.0% (95% CI: -74.8%, -15.2%)]. An upward trend in outpatient flow was observed after the war [1,219.4 (95% CI: 326.1, 2,112.8)]. CONCLUSIONS: The present study has clearly indicated that the war and COVID-19 have led to a large reduction in admissions, outpatient attendance, and emergency department visits. The evidence from this study suggests that due to this double catastrophe, thousands of patients could not gain access to healthcare, with probable negative consequences. Governments and organizations should implement measures to buttress the healthcare system to maintain pre-war status of service.

Clinical presentation, maternal-fetal, and neonatal outcomes of early-onset versus late onset preeclampsia-eclampsia syndrome in a teaching hospital in a low-resource setting: A retrospective cohort study.

BACKGROUND: Pre-eclampsia-eclampsia syndrome remains the leading cause of maternal and neonatal mortality worldwide. Both from pathophysiologic and clinical stand points, early and late onset preeclampsia are thought to be two different disease entities. However, the magnitude of preeclampsia-eclampsia and maternal-fetal and neonatal outcomes of early and late onset preeclampsia are not adequately investigated in resource-limited settings. This study sought to examine the clinical presentation and maternal-fetal and neonatal outcome of these two entities of the disease in Ayder comprehensive specialized hospital, an academic setting in Tigray, Ethiopia, from January 1, 2015-December 31, 2021. METHODS: A retrospective cohort design was employed. The patient charts were reviewed to see the baseline characteristics and their progress from the onset of the disease in the antepartum, intrapartum and postpartum periods. Women who developed pre-eclampsia before 34 weeks of gestation were defined as having early-onset pre-eclampsia, and those who developed at 34 weeks or later were identified as late-onset preeclampsia. We used chi-square, t-test and multivariable logistic regression analyses to determine differences between early- and late onset diseases in terms of clinical presentation, maternal-fetal, and neonatal outcomes. RESULTS: Among the 27,350 mothers who gave birth at the Ayder comprehensive specialized hospital, 1095 mothers had preeclampsia-eclampsia syndrome, with a prevalence of 4.0% (95% CI: 3.8, 4.2)]. Of the 934 mothers analyzed early and late onset diseases accounted for 253 (27.1%) and 681 (72.9%) respectively. Overall, death of 25 mothers was recorded. Women with early onset disease had significant unfavorable maternal outcomes including having preeclampsia with severity features (AOR = 2.92, 95% CI: 1.92, 4.45), liver dysfunction (AOR = 1.75, 95% CI: 1.04, 2.95), uncontrolled diastolic blood pressure (AOR = 1.71, 95% CI: 1.03, 2.84), and prolonged hospitalization (AOR = 4.70, 95% CI: 2.15, 10.28). Similarly, they also had increased unfavorable perinatal outcomes, including the APGAR score at the 5th minute (AOR = 13.79, 95% CI: 1.16, 163.78), low birth weight (AOR = 10.14, 95% CI 4.29, 23.91), and neonatal death (AOR = 6.82, 95% CI: 1.89, 24.58). CONCLUSION: The present study highlights the clinical differences between early versus late onset preeclampsia. Women with early-onset disease are at increased levels of unfavorable maternal outcomes. Perinatal morbidity and mortality were also increased significantly in women with early onset disease. Therefore, gestational age at the onset of the disease should be taken as an important indicator of the severity of the disease with unfavorable maternal, fetal, and neonatal outcomes.

Patterns of Medical Admissions and Predictors of Mortality in Ayder Comprehensive Specialized Hospital, Northern Ethiopia: A Prospective Observational Study.

Background: Previous works show that noncommunicable diseases (NCDs) are on the rise in developing nations, including Ethiopia, in the background of preexisting communicable diseases (CDs). Data on hospital admission in sub-Saharan Africa are scarce, particularly prospectively collected, and hence this study was done to close the gap in acquiring accurate diagnosis usually faced with retrospective data. We aimed to describe medical admission patterns, their outcomes and determinants at Ayder Comprehensive Specialized Hospital (ACSH) in Tigray, Ethiopia. Methods: Data were collected prospectively from November 1, 2017 to October 31, 2018 for all medical admissions. Sociodemographic profiles, final diagnosis, outcome of hospitalization, and complications were recorded using a data-abstraction checklist. Data were analyzed using SPSS 26. Results: There were 2084 medical admissions over 1 year. Median age was 45 years (IQR 31). A majority (1107, 53.1%) were male. The age-group 25-34 years had the most admissions (19.0%). NCDs constituted 68.2% of admissions. According to the International Classification of Diseases, patients were admitted most frequently due to disease of the circulatory system (36.7%) followed by infectious or parasitic diseases (24.1%). Of NCDs, cardiovascular diseases contributed to 53.9%, followed by cancers (8.6%). Of CDs, HIV/AIDS contributed to 31.3%, followed by tuberculosis (22.8%). A total of 1375 (66%) were discharged improved, while 311 (14.9%) died. On multivariate analysis, the in-hospital mortality was significantly higher (18.7%) for CDs than NCDs (13.2%, AOR 1.8, 95% CI 1.4-2.3; P<0.001). Bed occupancy of ACSH medical wards and ICU was 54%. Conclusion: NCDs were leading causes of medical admissions in ACSH. The presence of CDs and the development of complications were associated with higher risk of death. Attention should be given by policy-makers to curb the higher morbidity from NCDs and mortality from CDs.

Prevalence, Clinical Profile and Risk Factors of Nosocomial Infection in Ayder Pediatric Intensive Care Unit, Tigray, Ethiopia.

Background: Hospital-acquired infection (HAI) is a significant cause of increased morbidity and mortality amongst hospitalized patients and represents a considerable health and economic burden worldwide. However, evidence about HAI in pediatric ICU is limited. Objective: To identify the prevalence of hospital-acquired infection (HAI), clinical profile, and its risk factors for nosocomial infection in patients admitted to the pediatric intensive care unit (PICU). Methodology: From a two-year retrospective chart review admitted from 2019 to 2020 to the PICU, 223 patients were selected by systematic random sampling. Data were analyzed in SPSS version 23.0. P-values <0.05 were considered significant for all tests. Results: Forty-five (20.2%) patients developed nosocomial infection (NI). The median age was 4 years with 25-50th IQR of (0.6-9). About invasive procedures done, the most common was nasogastric tube (57%), followed by mechanical ventilation (17.9%) and urinary catheter (13.9%). The main focus of the infection was chest (53.3%), followed by bloodstream infection (22%) and gastrointestinal infection (9%). The odds of HAI were 3.3 times higher among under-five compared to those aged between 5 and 18 years (AOR: 3.3, 95% CI = 1.4-8.0, p = 0.008). The odds of HAI were also 4.1 times higher in those who stayed for more than two weeks compared to those who stayed in the pediatric ICU 2 to 14 days (AOR: 4.1, 95% CI = 2.0-8.6, p < 0.001). The mean duration of mechanical ventilation in those patients with and without NI was 1.65 days and 13.96 days, respectively (AOR = 3.46, 95% CI = 1.44-9.81, p = 0.02). Patients who started antibiotics at admission and patients who were on nasogastric tube feeding were also statistically significant risk factors for developing NI (AOR = 2.67, 95% CI = 1.37-9.64, p = 0.02; AOR = 2.45, 95% CI = 1.64-6.53, p = 0.03). Conclusion: The rate of infection in this study was higher compared to some developing countries. Younger age and prolonged length of hospital stay were found to be significant risk factors for HAI.

Time to Recovery of Severely Ill COVID-19 Patients and its Predictors: A Retrospective Cohort Study in Tigray, Ethiopia.

Background: COVID-19 is one of the leading causes of morbidity and mortality and is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). A patient infected with SARS-CoV-2 is said to be recovered from the infection following negative test results and when signs and symptoms disappear. Different studies have shown different median recovery time of patients with COVID-19 and it varies across settings and disease status. This study aimed to assess time to recovery and its predictors among severely ill COVID-19 patients in Tigray. Methods: A total of 139 severely ill COVID-19 patients who were hospitalized between May 7, 2020 and October 28, 2020 were retrospectively analyzed. Cox proportional hazard regression model was fitted to identify the risk factors associated with the time duration to recovery from severe COVID-19 illness. Results: The median age of the patients was 35 years (IQR, 27-60). Eighty-three (59.7%) patients recovered with a median time of 26 days (95% CI: 23-27). The results from the multivariable analysis showed that the recovery time was lower for severely ill patients who had no underline comorbidity diseases (AHR=2.48, 95% CI: 1.18-5.24), shortness of breath (AHR=2.08, 95% CI: 1.07-3.98) and body weakness (AHR=2.62, 95% CI: 1.20-5.72). Moreover, COVID-19 patients aged younger than 40 years had lower recovery time compared to patients aged 60 and above (AHR=4.09, 95% CI: 1.58-10.61). Conclusion: The median recovery time of severely ill COVID-19 patients was long, and older age, comorbidity, shortness of breath, and body weakness were significant factors related with the time to recovery among the severely ill COVID-19 patients. Therefore, we recommended that elders and individuals with at least one comorbidity disease have to get due attention to prevent infection by the virus. Moreover, attention should be given in the treatment practice for individuals who had shortness of breath and body weakness symptoms.

Nosocomial sepsis and drug susceptibility pattern among patients admitted to adult intensive care unit of Ayder Comprehensive Specialized Hospital, Northern Ethiopia.

OBJECTIVE: Developing nosocomial sepsis within intensive care unit (ICU) is associated with increased mortality, morbidity, and length of hospital stay. But information is scarce regarding nosocomial sepsis in intensive care units of Northern Ethiopia. Hence, this study aims to determine the incidence of nosocomial sepsis, associated factors, bacteriological profile, drug susceptibility pattern, and outcome among patients admitted to the adult ICU of Ayder Comprehensive Specialized Hospital (ACSH), which is the largest tertiary hospital in Northern Ethiopia. METHOD: Facility-based longitudinal study was conducted by following 278 patients who were admitted for more than 48 h to adult ICU of ACSH, from October 2016 to October 2017. Data were collected from charts, electronic medical records, and microbiology registration book using a checklist. The collected data were subjected to descriptive statistics and multivariable logistic regression using SPSS version 25. Statistical significance was declared at p < 0.05. RESULT: Of all the patients, 60 (21.6%) of them acquired nosocomial sepsis. The risk of mortality was about two times higher among adult ICU patients who acquired nosocomial sepsis (RR = 2.2; 95% CI of RR = 1.3-3.5; p = 0.003). The odds of acquiring nosocomial sepsis among those who were on a mechanical ventilator (MV) and stayed more than a week were 5.7 and 9.3 times higher, respectively, than their corresponding counterparts. Among 48 isolates, Klebsiella was the most common pathogen. The isolates had a broad antibiotic resistance pattern for cephalosporins, penicillins, and methicillin. CONCLUSION: The incidence of nosocomial sepsis in the adult ICU patients of ACSH was higher when compared to the incidence reported from some African and Asian countries. Mortality was higher among patients who acquired nosocomial sepsis. Use of MV and longer length of ICU stay were the significant predictors of nosocomial sepsis. The isolates were resistant to several antibiotics. Therefore, strict application of infection prevention strategies and appropriate use of antibiotics is so crucial. As well, priority should be given to patients who develop nosocomial sepsis in ICU.

Thyrotoxicosis and dilated cardiomyopathy in developing countries.

BACKGROUND: Thyrotoxicosis is the state of thyroid hormone excess. But, in sub-Saharan Africa (SSA), specifically Northern Ethiopia, scientific evidence about thyrotoxicosis and its cardiac complications like dilated cardiomyopathy is limited. Therefore, this study aimed to explore the thyrotoxicosis presentation and management and identify factors associated with dilated cardiomyopathy in a tertiary hospital in Northern Ethiopia. METHODS: An institution-based cross-sectional study was conducted in Ayder Comprehensive Specialized Hospital from 2017 to 2018. Data from 200 thyrotoxicosis cases were collected using a structured questionnaire. After describing variables, logistic regression was conducted to identify independent predictors of dilated cardiomyopathy. Statistical significance was declared at p < 0.05. RESULTS: Mean age at presentation of thyrotoxicosis was 45 years and females accounted for 89 % of the cases. The most frequent etiology was multinodular toxic goiter (51.5 %). As well, the most common symptoms and signs were palpitation and goiter respectively. Thyroid storm occurred in 6 % of the cases. Out of 89 patients subjected to echocardiography, 35 (39.3 %) of them had dilated cardiomyopathy. And, the odds of dilated cardiomyopathy were higher in patients who had atrial fibrillation (AOR = 15.95, 95 % CI:5.89-38.16, p = 0.001) and tachycardia (AOR = 2.73, 95 % CI:1.04-7.15, p = 0.040). All patients took propylthiouracil and 13.0 % of them experienced its side effects. Concerning ß-blockers, propranolol was the most commonly (78.5 % of the cases) used drug followed by atenolol (15.0 %). Six patients underwent surgery. CONCLUSIONS: In developing countries like Ethiopia, patients with thyrotoxicosis have no access to methimazole which is the first-line anti-thyroid drug. Besides, they greatly suffer from dilated cardiomyopathy (due to late presentation) and side effects of propylthiouracil. Therefore, we recommend that patients should get adequate health information about thyrotoxicosis and anti-thyroid drugs including their side effects. Additionally, hospitals and other concerned bodies should also avail of TSH tests and methimazole at an affordable cost. Furthermore, community awareness about iodized salt and iodine-rich foods should be enhanced.

Adverse events of Oxford/AstraZeneca's COVID-19 vaccine among health care workers of Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia.

Background: : The safety of COVID vaccines should be continuously followed. This study reports adverse events of the Oxford/AstraZeneca COVID-19 vaccine. Methods: : A prospective single-cohort study design was conducted to assess adverse events following immunization and associated factors of the first dose of Oxford/AstraZeneca's COVID-19 vaccine in Ayder Comprehensive specialized hospital. A structured questionnaire was administered consecutively to 423 participants. Follow-up data were collected 72 hours after vaccination via phone. Bivariate and multivariate logistic regression models were used to find associations between adverse events and independent variables. Statistical significance was declared at P<0.05. Results: : Out of 423 health care workers approached, 395 responded. At least one adverse event (95% CI: 63.58, 72.77) was reported by 270 participants. Local and systemic symptoms occurred in 46.8% (95% CI: 41.94, 51.79) and 58.48% (95% CI: 53.53, 63.26)], respectively. Muscle ache, fatigue, headache and fever were the most common local symptoms. No reports of hospitalization, disability or death. Age (adjusted odds ratio [AOR]=0.97, P=0.048), female sex (AOR=1.84, P=0.028), and comorbidity (AOR=2.28, P=0.040) were independent predictors of adverse events. Conclusion and recommendation: : Adverse events following immunization are commonly reported after the first dose of the Oxford/AstraZeneca COVID-19 vaccine; age, female sex and comorbidity are independent predictors.